Update on Cosmetic Botulinum Toxin in Oculofacial Plastic Surgery

Since its approval by the United States Food and Drug Administration (FDA) for cosmetic purposes, botulinum toxin A (Botox and BotoxCosmetic) has become the most frequently used treatment for cosmetic procedures. Of the many clinical applications that have been developed for improving the external appearance of patients, perhaps the two most exciting uses of botulinum toxin in recent years are for eyebrow shaping and for facial skin rejuvenation in adjunct with injectable fillers or skin resurfacing. This article will examine these and other recent developments in the use of cosmetic Botox including new studies designed to delineate the precise dosages that should be administered to various facial locations, the use of Botox below the eyes, and patient outcome studies.

Practical Aspects of Cosmetic Botulinum Toxin

Although Botox manufacturer Allergan recommends using preservative-free saline, normal saline with preservative has been reported to decrease the pain of injection. Recent studies suggest that minimizing injection volume can minimize unwanted side effects due to diffusion. A common practice is to place 4 mL of diluting saline in the Botox bottle to get a final concentration of 2.5 Units / 0.1 mL. Most clinicians currently reconstitute the toxin immediately and do not refreeze it or store it. Patient selection and consultation is critical in achieving outcomes that match patient expectations. The precise treatment dose and location should be documented on appropriate forms, photos, or schematics. Pre- and post-treatment photographic documentation (at various angles and magnification) both at rest and with maximal facial muscle contraction are necessary.

Adjunctive Uses of Botulinum Toxin

Botulinum toxin weakens the facial muscles that cause hyperdynamic facial skin wrinkles. Other types of facial skin wrinkles are static lines from chronic ultraviolet light exposure and skin troughs due to relative soft tissue volume shortage. Epidermal and dermal sun damage may be treated with various chemical peels, dermabrasion, and/or resurfacing with lasers or other energy sources. Skin volume loss may be treated with temporary or permanent injectable fillers, fat injection, and/or surgical placement of alloplastic implants, etc. Carruthers and Carruthers have found that Botox used with either injectable fillers or skin resurfacing augments the effect of Botox used alone (Int Ophthalmol Clin. 2005;45(3):143-151).

Additionally, these researchers have found through multiple, prospective, randomized studies that patients, particularly men, can tolerate increased dosages of Botox around the eyes. This is due to the fact that men have larger facial muscles and thicker skin. Carruthers and Carruthers recommend administering 40-80 units of botulinum toxin in the glabella for men and 20-40 units for women (Dermatol Surg. 2005;31(4):414-422 and Dermatol Surg. 2005; 31(10):1297-1303). In the crow’s feet region near the lateral canthus only 10-15 units per side is required in both sexes.

Modifying Brow Position

Using Botox, Foster and colleagues successfully elevated and shaped patient eyebrows through a chemical brow lift capable of raising the eyebrows 1-4 mm (Int Ophthalmol Clin. 2005;45(3):123-131). Patients with brow ptosis or asymmetry can receive Botox directly near their brows to selectively elevate or lower them as needed. For example, placing Botox in the superolateral orbicularis oculi muscle can elevate the lateral eyebrow by weakening the lateral eyebrow depressor (Int Ophthalmol Clin. 2005;45(3):39-47). Similarly, placing Botox in the medial glabella (corrugator supercilii muscle) can elevate the medial eyebrow by weakening the medial eyebrow depressor. Conversely, Botox injected into the frontalis muscle may lower the eyebrows by weakening the eyebrow elevating muscle.

Botulinum Toxin Below the Eyes

Ophthalmologists should be aware of the burgeoning use of Botox for facial regions below the eyes. These indications were reported several years ago and are now becoming more mainstream. In the mid face, for example, botulinum toxin can help to reduce lower lid orbicularis hypertrophy, horizontal nasal lines (bunny lines), masseteric (cheek) hypertrophy, and melolabial folds (Int Ophthalmol Clin. 2005;45(3):133-141). In the lower face, Botox may reduce mouth frowning, mouth droop lines, and chin creases or wrinkles. In general, doses used in the mid and lower face are much smaller (i.e., 1-4 units/site) than those used in the upper face, due to such potential side effects as mouth and lip droop, dysarthria, dysphagia, and dysphonia.

Measuring Patient Outcomes

The interpretation of facial expression is an integral component of interpersonal communication, and its attractiveness influences how one is perceived by others. Emotions such as anger, anxiety, irritation, sadness, or worry (Int Ophthalmol Clin. 2005;45(3):1-11) are conveyed through the face, but so is apparent age. Because individual self-perception and self-esteem are influenced by how one is perceived by others, patient-derived satisfaction studies like the Facial Line Treatment Satisfaction Questionnaire (FLTSQ) have consistently shown that patients often choose botulinum toxin treatment to minimize facial wrinkles, so they can look more youthful, and to better control the appearance of such emotions as anger, anxiety, irritation, sadness, and worry on the face.

Indeed, according to the FLTSQ, patients attributed their improved, relaxed, rested, and younger appearances to Botox treatment. Patients also noted that they felt more competitive at work and more confident. The FLTSQ documents clinically and statistically significant information regarding patient satisfaction after botulinum toxin treatment, and it has been verified as a reliable and valid measure of patient outcomes (Int Ophthalmol Clin. 2005;45(3):13-24). Ophthalmologists can look forward to obtaining the best possible aesthetic outcomes for their patients as more experience is gained from the cosmetic use of botulinum toxin.

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Author Disclosure

The author states that he has no significant financial relationship with the manufacturer or provider of any product or service discussed in this article or with the manufacturer or provider of any competing product or service.